post-MI Patients Research Articles

Prognosis in patients with prior myocardial infarction and PEGASUS-TIMI 54 criteria in the CLARIFY registry

Abstract Background/Introduction The PEGASUS-TIMI 54 trial showed that prolonged treatment with ticagrelor reduces the cumulative occurrence of ischemic adverse events. CLARIFY is the biggest real life registry on chronic coronary syndrome. Purpose - To evaluate the percentage of patients eligible for long-term ticagrelor therapy in the CLARIFY registry. – To compare the outcome of this subgroup of patients with those with PEGASUS exclusion criteria or without PEGASUS inclusion criteria. Methods Within the CLARIFY population, we selected post MI patients and we excluded those with missing info (post MI evaluable population). Then, we divided patients into 3 groups: excluded (meeting PEGASUS exclusion criteria, namely use of P2Y12 receptor antagonists or chronic oral anticoagulant, any stroke, coronary-artery bypass grafting in the past 5 years); eligible (meeting PEGASUS high-risk inclusion criteria, namely age≥65 years; diabetes; multivessel disease; creatinine clearance <60 ml/min) and ineligible (not meeting PEGASUS high-risk inclusion criteria). We therefore compared the ischemic (CV death, MI and stroke) and bleeding (major bleeding) outcome of the 3 groups adjusting for age, sex, smoking and geographical region. Results Among the 11811 post-MI evaluable patients, 4706 (39.8%) were included in the eligible group, 5715 (48.4%) in the excluded group, and 1390 in the ineligible group (11.8%). Both the ischemic and bleeding endpoints were significantly different among the 3 groups with the excluded patients with the worst and ineligible patients with the best outcome (see table). The same trend was shown for CV death, while the occurrence of MI was not significantly different among the 3 groups. In the eligible group, the ratio between ischemic and bleeding events was 6:1, whereas between CV death and major bleeding was 3.5:1. Conclusions Around 40% of CLARIFY post-MI patients could benefit from prolonged ticagrelor therapy. In this group of patients, ischemic risk seems to be higher than the bleeding one. Ischemic & bleeding risk in the 3 groups Funding Acknowledgement Type of funding source: Private company. Main funding source(s): CLARIFY registry was funded by Servier

Risk stratification on echocardiography and outcome in ischaemic mitral regurgitation

Abstract Background Ischaemic mitral regurgitation (IMR) confers a poor prognosis. Transcatheter intervention may improve survival but benefit is likely to depend on severity of IMR relative to LV remodelling following myocardial infarction (MI). In theory, those with “discordant” IMR (significant regurgitant volume without severe LV dilatation or impairment), are expected to benefit most from mitral intervention. While subcategorization may help to inform treatment, there are no data on post-MI patients in this respect. Purpose To determine the incidence of discordant & concordant IMR categorised on echocardiography post-MI and impact on outcomes. Methods 1000 consecutive patients admitted to our hospital with myocardial infarction who underwent coronary angioplasty were included. Early inpatient TTE was performed by accredited echocardiographers using standard multiparametric quantification. Using TTE parameters, 4 subgroups were identified (figure) according to the degree of MR relative to LV remodelling. Thresholds were based on European guidelines (± 2SD from normal) and median value among survivors for vena contracta (VC): – LVEF: 52% (♂), 54% (♀) – Indexed LV end diastolic volume (LVEDVi): 74ml/m2 (♂), 61ml/m2 (♀) – Effective regurgitant orifice area (EROA) ≥0.2cm2 – Regurgitant volume (RVol) ≥30ml – VC ≥0.5cm Results MR was seen in 294/1000 patients (29.4%) with a severity of mild (76%), moderate (21%) and severe (3%). Concordant and discordant IMR were each seen in 16/294 (5%) of IMR patients post-MI. After a mean follow up of 3.2 years, IMR patients had a 3% rate of heart failure (HF) within 1 year and 19% mortality. Non-survivors had significantly worse IMR (PISA 0.65±0.25cm vs 0.54±0.19cm; p=0.033; VC 0.63±0.25cm vs 0.49±0.18cm; p=0.014), worse LV function (LVEF 44±17% vs 51±13%; p<0.001), larger LV (LVEDVi 67±23ml/m2 vs 60±22ml/m2; p=0.032) and larger indexed LA volume (LAVi) (44±22ml vs 35±15ml; p<0.001). Those with concordant IMR had the worst survival (50%) although almost 1 in 5 of those with discordant MR died within the follow up period (19%). Using multivariable Cox regression, significant predictors of mortality included LVEF (p<0.001; HR 0.96, 0.94–0.98) and LAVi (p<0.001; HR 1.02, 1.01–1.03) but not LVEDVi. Conclusion 1) Significant predictors of mortality in IMR include LA dilatation and decline in LVEF, but not LV dilatation. 2) Although discordant severe IMR is uncommon following MI, mortality if left untreated remains high. Attention should be paid to early selection of this cohort for intervention. Funding Acknowledgement Type of funding source: None

Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach

Abstract Background Although some post myocardial infarction (post-MI) and dilated cardiomyopathy (DCM) patients with mid-range ejection fraction heart failure (HFmrEF = 40–49%) face an increased risk for arrhythmic Sudden Cardiac Death (SCD), current guidelines do not recommend an implantable cardioverter-defibrillator (ICD). Purpose To assess the accuracy of a novel multifactorial two-step approach, with noninvasive risk factors (NIRFs) leading to programmed ventricular stimulation (PVS), for SCD risk stratification of hospitalized HFmrEF patients. Methods Forty-eight patients (male=83%, age = 64±14 years, LVEF = 45±5%, ischemic coronary disease = 69%) underwent a NIRF presence screening first step with ECG, SAECG, echocardiography and 24 hour ambulatory ECG (Holter). Thirty-two patients with presence of one out of three NIRFs (SAECG ≥2 positive criteria for late potentials, ventricular premature beats ≥240/24 hours, and ≥1 episode of non-sustained ventricular tachycardia on Holter) were further stratified with PVS. Patients were classified as either low (Group 1, n=16, NIRFs−), moderate (Group 2, n=18, NIRFs+ /PVS−) or high risk (Group 3, n=14, NIRFs+/PVS+). All Group 3 patients received an ICD. Results After 41±18 months, 9 out of 48 patients experienced the major arrhythmic event (MAE) endpoint (clinical ventricular tachycardia/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 & 2 (2/34, 5.8%). A logistic regression model adjusted for PVS, age and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618–170.887, p=0.004). Kaplan Meier curves diverged significantly (p logrank <0.001) while PVS negative predictive value was 94%. Conclusion In hospitalized HFmrEF post-MI and DCM patients, a NIRFs leading to PVS two-step approach efficiently detected the subgroup at increased risk for MAEs. Funding Acknowledgement Type of funding source: None

Effect of a lifestyle-focused electronic patient support application on risk factor management in post-myocardial infarction patients – a randomized controlled trial

Abstract Background Cardiac rehabilitation (CR) is central in reducing morbidity and mortality after myocardial infarction (MI). However, the fulfillment of guideline recommended CR targets is unsatisfactory. eHealth offers new possibilities to improve clinical care. Purpose The aim of this study was to assess the efficacy of a mobile device application to support adherence to lifestyle advice and self-control of risk factors as a complement to traditional CR after MI. Method This unblinded multi-centre randomized controlled trial included 150 patients with MI (81% men, 60.4±8.8 years). All patients in the intervention (INT) and control (CON) groups participated in a 1-year CR program. Additionally, INT patients (n=101) received access to the mobile device application for 25 weeks post-MI where information about lifestyle (i.e., diet, physical activity, smoking), modifiable risk factors (i.e., weight, blood pressure (BP)), and symptoms could be registered. The software provided direct positive feedback and lifestyle advice. Data was reviewed twice weekly by the CR nurse. The primary outcome was change in sub-maximal exercise capacity (W) between an exercise test 2-weeks post MI and at follow-up 4 month later. Secondary outcomes included changes in lifestyle and modifiable risk factors including body mass index, waist circumference, blood-lipids, fasting glucose and HbA1c, between baseline and 2-week, 2-month and 1-year follow-up visits. Regression analysis was used, adjusting for relevant baseline variables. Results Participation in CR was high, with 96% of INT patients and 98% of the CON patients attending the 1-year follow-up visit. Forty-six percent of the INT patients and 57% of the CON patients attended centre-based exercise training (p=0.1). In the INT group 86% logged data in the application at least once. Adherence, defined as logging data at least twice per week, was 92% in week 1 and 57% in week 25. There was a numerical trend toward better exercise capacity improvement in the INT group (INT +14.4±19.0 vs. CON +10.3±16.1 W, p=0.2) although differences were non-significant. INT patients achieved larger BP reduction at 2-weeks (systolic) and 2-months (systolic and diastolic) (Figure). At 2-months 70% vs. 46% of smokers in the INT vs CON groups had quit smoking, and at 1-year the respective percentages were 57% vs. 36%. The number of smokers in the study was however low (n=33) and the differences non-significant. For other secondary endpoints no differences were observed. Conclusion Complementing CR with a mobile device application improved BP during the first months after MI, and non-significant trends towards better exercise capacity and higher smoking cessation rates were observed. Even though the differences were non-significant in our small study sample, they indicate that using eHealth in the form of a mobile device application could clinically benefit post-MI patients participating in CR. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Governmental funding of clinical research within the National Health Services in Sweden.

Experimental and population-genetic evidence for inflammation control functions of long noncoding RNAs and a novel tRNA-like transcript arising from the human NEAT1-MALAT1 genomic region

Abstract Background Uncontrolled inflammation is a key driver of atherosclerosis, myocardial infarction (MI), and multiple other diseases. Beyond proteins and microRNAs, long noncoding RNAs (lncRNAs) are implicated in inflammation control. We previously reported suppression of lncRNA NEAT1 in circulating immune cells of post-MI patients. In mice lacking lncRNAs NEAT1 or MALAT1 we observed major immune disturbances affecting monocyte-macrophage and T cell differentiation and rendering the immune system unstable and highly vulnerable to immune stress. Here, we report functions of a novel tRNA-type transcript arising from the NEAT1-MALAT1 gene cluster, and on genetic heterogeneity of this region in the human population. Methods and results While previously investigated mice were deficient in the entire NEAT1 or MALAT1 locus, we here aimed to selectively disrupted only the novel 59-nt tRNA-like transcript “menRNA” with hitherto unknown functions. Through CRISPR/Cas9 editing we developed 4 human THP-1 monocyte-macrophage cell line clones with deletions of different extension all of which prevented, however, normal transcript folding and formation of “menRNA”. Transcriptome mapping of all clones by RNA-sequencing identified dysregulation of innate immunity-related genes (IFI16, IFITM3, IRAK3, IRF2BP2, IRF3), chemokine and interleukin receptors (CCR10, IL11RA, IL12RB2, IL23A), cell surface receptors (CD37, CD40LG, CD72, FOCAD, ITGA6, MAEA, THY1), macrophage function-associated genes (ELANE, GRN, MIF, MMP25, MST1P2, PRTN3), tRNA-processing transcripts (GARS, QRSL1P3, QTRT1P1, THG1L, VARS), and small nucleolar RNAs (SNORA26.62.64, SNORD65.112). These data and functional assays indicate functions of NEAT1-derived “menRNA” distinct from those previously described for MALAT1-derived mascRNA. As multiple data suggest inflammation control functions of the NEAT1-MALAT1 region, we investigated the extent of genetic variability of this region in humans. In cohorts from the SHIP study coordinated by the Institute for Community Medicine Greifswald, screening of this region for sequence variants and possible phenotype associations was conducted the results of which are given in Figure 1. Consistent with prior findings, a MALAT1 SNP with very low minor allele frequency (MAF=0.01) was associated (p=0.0062) with systemic low level inflammation (CRP >3.0 mg/L). Unexpected was the association (p<0.01) of eight SNPs (low MAF=0.09 for all) with BMI >35 kg/m2 and LDL >164 mg/dl. Conclusions First, selective disruption of menRNA formation in human monocyte-macrophages provides evidence that this novel type of noncoding RNA has immunoregulatory functions. Second, the phenotype associations of SNPs within the NEAT1-MALAT1 gene cluster warrant further in-depth investigation of the molecular basis of these associations, and of their allele frequencies in cardiovascular disease patient cohorts. The first three and the last authors contributed equally to this work. Figure 1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): “Transcriptome analysis of circulating immune cells to improve the assessment of prognosis and the response to novel anti-inflammatory treatments after myocardial infarction”; DZHK Shared Expertise project B19-006_SE FKZ 81X2100257

Prevalence and prognostic impact of left ventricular systolic dysfunction after acute myocardial infarction

Abstract Background Left ventricular dysfunction after an acute myocardial infarction (MI) is associated with poor outcome. The PARADISE-MI trial is examining whether an angiotensin receptor-neprilysin inhibitor reduces the risk of cardiovascular death or worsening heart failure (HF) in this population. The aim of this study was to examine the prevalence and prognosis of different subsets of post-MI patients in a real-world setting. Additionally, the prognostic importance of some common risk factors used as risk enrichment criteria in the PARADISE-MI trial were specifically examined. Methods In a nationwide myocardial infarction registry (SWEDEHEART), including 87 177 patients with type 1 MI between 2011–2018, 3 subsets of patients were identified in the overall MI cohort (where patients with previous HF were excluded); population 1 (n=27 568 (32%)) with signs of acute HF or an ejection fraction (EF) <50%, population 2 (n=13 038 (15%)) with signs of acute HF or an EF <40%, and population 3 (PARADISE-MI like) (n=11 175 (13%)) with signs of acute HF or an EF <40% and at least one risk factor (Age ≥70, eGFR <60, diabetes mellitus, prior MI, atrial fibrillation, EF <30%, Killip III-IV and STEMI without reperfusion therapy). Results When all MIs, population 1 (HF or EF <50%), 2 (HF or EF <40%) and 3 (HF or EF <40% + additional risk factor (PARADISE-MI like)) were compared, the median (IQR) age increased from 70 (61–79) to 77 (70–84). Also, the proportion of diabetes (22% to 33%), STEMI (38% to 50%), atrial fibrillation (10% to 24%) and Killip-class >2 (1% to 7%) increased. After 3 years of follow-up, the cumulative probability of death or readmission because of heart failure in the overall MI population and in population 1 to 3 was 17.4%, 26.9%, 37.6% and 41.8%, respectively. In population 2, all risk factors were independently associated with death or readmission because of HF (Age ≥70 (HR (95% CI): 1.80 (1.66–1.95)), eGFR <60 (1.62 (1.52–1.74)), diabetes mellitus (1.35 (1.26–1.44)), prior MI (1.16 (1.07–1.25)), atrial fibrillation (1.35 (1.26–1.45)), EF <30% (1.69 (1.58–1.81)), Killip III-IV (1.34 (1.19–1.51)) and STEMI without reperfusion therapy (1.34 (1.21–1.48))) in a multivariable Cox regression analysis. The risk increased with increasing number of risk factors (Figure 1). Conclusion Depending on definition, post MI HF is present in 13–32% of all MI patients and is associated with a high risk of subsequent death or readmission because of HF. The risk increases significantly with every additional risk factor. There is a need to optimize management and improve outcomes for this high risk population. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Novartis

Risk stratification and secondary prevention post-myocardial infarction: insights from the EYESHOT Post-MI study.

Clinical management of patients more than 1 year after acute myocardial infarction (MI) is challenging. Patient risk stratification may help to establish therapeutic priorities. We aimed to describe the comprehensive risk profile and management of patients with prior MI. We analyzed data from the EYESHOT Post-MI study, which evaluated the management of patients 1-3 years after MI. The risk profile of participants was defined according to the qualifying high-risk features of the PEGASUS-TIMI 54 trial (history of diabetes, history of recurrent MI, angiographic evidence of multivessel coronary disease, chronic kidney disease with estimated glomerular filtration rate <60 ml/min, age ≥65 years). Patients were classified into five subgroups according to the presence of zero, one, two, three, or more than three features. Of the 1633 patients in the EYESHOT Post-MI study, 1008 could be stratified according to PEGASUS-TIMI 54 high-risk features. About 22% of patients had no high-risk features, whereas 25% showed at least three features. The prevalence of patients with specific clinical severity indicators was progressively higher with the increasing number of high-risk features. Dual antiplatelet therapy and oral anticoagulation were more frequently used in patients with an increasing number of high-risk features (P for trend <0.0001). Lipid-lowering therapies were less frequently prescribed in patients with a higher number of features (P for trend 0.006 for statins; P for trend 0.007 for ezetimibe). Higher-risk post-MI patients, identified by PEGASUS-TIMI 54 high-risk features, showed an increased prevalence of major clinical severity indicators. Secondary prevention therapies were not adequately implemented in higher-risk patients.

Impaired left ventricular global longitudinal strain is associated with elevated left ventricular filling pressure after myocardial infarction.

Left ventricular (LV) global longitudinal strain (GLS) has emerged as a significant prognostic marker in patients after myocardial infarction (MI). Although elevated LV filling pressure after MI might alter GLS, direct evidence for this is lacking. This study aimed to clarify the association between GLS and LV filling pressure in a large animal MI model. A total of 104 Yorkshire pigs underwent both echocardiographic and hemodynamic assessments 1-4 wk after induction of large anterior MI. GLS was measured in the apical four-chamber view using a semiautomated speckle-tracking software. LV pressure-volume relationship was invasively measured using a high-fidelity pressure-volume catheter. GLS >-14% was considered impaired. Compared with pigs with LV ejection fraction (LVEF) >40% and preserved GLS (n = 29), those with LVEF >40% and impaired GLS (n = 37) and those with LVEF ≤40% (n = 38) had significantly higher LV end-diastolic pressure (15.5 ± 5.5 vs. 19.7 ± 5.8 and 19.6 ± 6.6 mmHg; P = 0.008 and P = 0.026, respectively) and higher LV mean diastolic pressure (7.1 ± 2.9 vs. 10.4 ± 4.5 and 11.1 ± 5.4 mmHg; P = 0.013 and P = 0.002, respectively). GLS was modestly correlated with τ (r = 0.21, P = 0.039) and slope of LV end-diastolic pressure-volume relationship (r = 0.43, P < 0.001). Impaired GLS was associated with higher LV end-diastolic and mean-diastolic pressures after adjusting for LVEF and baseline characteristics (P = 0.026 and P = 0.001, respectively). Impaired GLS assessed by speckle-tracking echocardiography was associated with elevated LV filling pressure after MI. GLS has an incremental diagnostic value for detecting elevated LV filling pressure and may be particularly useful for evaluating post-MI patients with preserved LVEF.NEW & NOTEWORTHY Strain analysis was performed in 104 pigs after MI, and its relationship to invasive hemodynamic measurements was studied. Impaired longitudinal strain was associated with high ventricular filling pressure independent of LVEF in post-MI setting. Global longitudinal strain is a potential prognostic marker after MI.

Proposal for a standardized discharge letter after hospital stay for acute myocardial infarction.

In patients admitted for acute myocardial infarction, the communication and transition from specialists to primary care physicians is often delayed, and the information imparted to subsequent healthcare providers (HCPs) may be sub-optimal. A French group of cardiologists, lipidologists and diabetologists decided to establish a consensus to optimize the discharge letter after hospitalization for acute myocardial infarction. The aim is to improve both the timeframe and the quality of the content transmitted to subsequent HCPs, including information regarding baseline assessment, procedures during hospitalization, residual risk, discharge treatments, therapeutic targets and follow-up recommendations in compliance with European Society of Cardiology guidelines. A consensus was obtained regarding a template discharge letter, to be released within two days after patient's discharge, and containing the description of the patient's history, risk factors, acute management, risk assessment, discharge treatments and follow-up pathway. Specifically for post acute MI patients, tailored details are necessary regarding the antithrombotic regimen, lipid-lowering and anti-diabetic treatments, including therapeutic targets. Lastly, the follow-up pathway needs to be precisely mentioned in the discharge letter. Additional information such as technical descriptions, imaging, and quality indicators may be provided separately. A template for a standardized discharge letter based on 8 major headings could be useful for implementation in routine practice and help to improve the quality and timing of information transmission between HCPs after acute MI.

Experiencia de 5 años en soporte circulatorio mecánico de corta duración en pacientes post infarto de miocardio: Un reporte del registro INCORMACS

Objetivo. Determinar las características clínicas y epidemiológicas de los pacientes con dispositivos de soporte mecánico circulatorio (DSMC) de corta duración, posinfarto de miocardio (IAM) en un hospital de referencia nacional.&#x0D; Materiales y métodos. Estudio descriptivo, retrospectivo, de pacientes post IAM en los que se implantó dispositivos de soporte mecánico circulatorio de corta duración desde el año 2015 al 2020.&#x0D; Resultados. Se implantaron nueve dispositivos de asistencia en igual número de pacientes debido a choque cardiogénico post-IAM. Todos los pacientes fueron varones con IAM con elevación del segmento ST (IAMCEST). Se implantaron ocho dispositivos de oxigenación por membrana extracorpórea (ECMO) y una bomba de flujo centrífugo (en configuración LVAD). La mediana de tiempo de uso del dispositivo fue de ocho días. Las complicaciones más frecuentes fueron la hemorragia no fatal (55,6%), injuria renal aguda (44,4%) y la sepsis (44,4%). La mortalidad intrahospitalaria fue de 55,6%.&#x0D; Conclusiones. El uso de DSMC de corta duración posinfarto de miocardio es aún limitado en nuestra institución y tiene como principal representante al ECMO post-IAMCEST complicado con choque cardiogénico. A pesar del uso de estos dispositivos la mortalidad intrahospitalaria es elevada.

Racial disparities in sleep disturbances among patients with and without coronary artery disease: The role of clinical and socioeconomic factors

ObjectiveTo investigate differences in sleep quality by race in participants with and without a prior myocardial infarction (MI). DesignCase-control study. SettingEmory-affiliated hospitals in Atlanta, Georgia. ParticipantsTwo hundred seventy-three individuals (190 Black) ≤60 years of age with a verified MI in the previous 8 months, and 100 community controls (44 Black) without a history of MI. MeasurementsSleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Psychological factors were assessed using standardized questionnaires and clinical risk factors through medical history and chart review. ResultsA significant interaction existed between race and MI status on sleep quality (P= .01), such that Black individuals with a history of MI, but not controls, reported worse sleep quality than their non-Black counterparts. Among MI cases, being Black was independently associated with higher PSQI scores after adjusting for baseline demographics (B = 2.17, 95% confidence interval 1.17, 3.17, P = .006). Clinical risk factors, psychological factors and socioeconomic status (household income and years of education) all contributed equally to explain race-related disparities in sleep among MI cases. After further adjustment for these factors, the association was attenuated and no longer significant (B = 0.70, 95% confidence interval = −0.10, 1.21, P = .26). ConclusionBlack post-MI patients, but not healthy controls, have significantly poorer sleep quality than non-Blacks. This difference is driven by a combination of factors, including clinical risk factors, psychological factors as well as adverse socioeconomic conditions among Black individuals with MI.

Premature ventricular complex site of origin and ablation outcomes in patients with prior myocardial infarction

Frequent premature ventricular complexes (PVCs) are common after a myocardial infarction (MI), but data on PVC ablation in this population are limited. The purpose of this study was to analyze data on PVC ablation in post-MI patients. Three hundred thirty-two patients with frequent PVCs and left ventricular (LV) dysfunction were prospectively studied. Data from 67 patients (20%; age 63 ± 10 years; 65 men [93%]) with previous MI were compared with the remaining 265 patients. PVCs in post-MI patients originate predominantly from the LV (92% LV vs 6% right ventricle [RV]; P <.001). The most frequent sites of origin (SOO) were MI scar in 23 patients (34%) and left ventricular outflow tract (LVOT) in 22 patients (33%). A papillary muscle origin was more frequent in post-MI patients (16% vs 4%; P = .001), whereas an RV outflow tract origin was less frequent (1% vs 33%; P <.001) compared to patients without MI. In post-MI patients, PVC burden decreased from 29% ± 12% at baseline to 4.6% ± 7% (P <.001); left ventricular ejection fraction (LVEF) improved from 33.6% ± 8% to 42% ± 10% (P <.001); and New York Heart Association functional class improved from 2.1±0.7 to 1.4 ± 0.5 points (P <.001) at 12 months. Compared with the remaining 265 patients, there were no differences in acute ablation success (85% vs 85%; P = .45), complication rate (6% vs 6%; P = .41), or absolute improvement in LVEF (8.8 ± 10 vs 9.9 ± 11 absolute points; P = .38). PVC ablation significantly improves cardiac function and functional status in post-MI patients. PVCs predominantly originate from MI scar and LVOT. A papillary muscle SOO was found to be strongly associated with previous MI.

Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach.

BackgroundAlthough some post myocardial infarction (post‐MI) and dilated cardiomyopathy (DCM) patients with mid‐range ejection fraction heart failure (HFmrEF/40%‐49%) face an increased risk for arrhythmic sudden cardiac death (SCD), current guidelines do not recommend an implantable cardiac defibrilator (ICD). We risk stratified hospitalized HFmrEF patients for SCD with a combined non‐invasive risk factors (NIRFs) guiding to programmed ventricular stimulation (PVS) two‐step approach.MethodsForty‐eight patients (male = 83%, age = 64 ± 14 years, LVEF = 45 ± 5%, CAD = 69%, DCM = 31%) underwent a NIRFs screening first‐step with electrocardiogram (ECG), SAECG, Echocardiography and 24‐hour ambulatory ECG (AECG). Thirty‐two patients with presence of one of three NIRFs (SAECG ≥ 2 positive criteria for late potentials, ventricular premature beats ≥ 240/24 hours, and non‐sustained ventricular tachycardia [VT] episode ≥ 1/24 hours) were further investigated with PVS. Patients were classified as either low risk (Group 1, n = 16, NIRFs−), moderate risk (Group 2, n = 18, NIRFs+/PVS−), and high risk (Group 3, n = 14, NIRFs+/PVS+). All in Group 3 received an ICD.ResultsAfter 41 ± 18 months, 9 of 48 patients, experienced the major arrhythmic event (MAE) endpoint (clinical VT/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 and 2 (2/34, 5.8%). Logistic regression model adjusted for PVS, age, and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618‐170.887, P = .004). Kaplan‐Meier curves diverged significantly (log rank, P < .001) while PVS negative predictive value was 94%.ConclusionsIn hospitalized HFmrEF post‐MI and DCM patients, a NIRFs guiding to PVS two‐step approach efficiently detected the subgroup at increased risk for MAE.

Medication adherence and its determinants in patients after myocardial infarction

Non-adherence to prescribed medication is a serious limitation of long-term treatment in patients after myocardial infarction (MI), which can be associated with medical, social and economical consequences. Improvement of medication adherence has been shown to be a challenge for healthcare providers. The aim of this study was to evaluate changes in medication adherence and variability of adherence determinants during follow-up in patients after MI. A single-center, cohort observational study was conducted in 225 post-MI patients treated with primary coronary intervention (PCI) (27% women and 73% men) aged 30–91 years. Adherence was defined as availability of evaluated drugs within 1-year after discharge from hospital, based on completed prescriptions data obtained from the National Health Fund. The analysis of therapeutic plan realization (adherence to medication prescribed at discharge from hospital) embraced only reimbursed drugs: ACEIs (ramipril, perindopril), P2Y12 receptor inhibitors (clopidogrel) and statins (atorvastatin, simvastatin, rosuvastatin). Sufficient adherence was defined as ≥ 80%. During 1-year follow-up, adherence for all three drug classes was 64 ± 25%, with 67 ± 32% for ACEIs, 62 ± 34% for P2Y12 receptor inhibitor and 64 ± 32% for statins. A gradual decline in adherence was observed from 65% ± 26% in the first quarter of follow-up to 51% ± 34% in the last quarter of follow-up (p < 0.00001). Sufficient adherence for all drugs classes was found only in 29% of patients throughout the whole follow-up period (44% for ACEI, 36% for P2Y12 receptor inhibitor and 41% for statins). According to a multivariate analysis, age, prior CABG, level of education, place of residence, economic status and marital status were independent predictors of drug adherence. Whereas patients > 65 years and having a history of prior CABG more often had an insufficient adherence to drugs, married and hypertensive patients, city inhabitants and patients with higher education tended to have a sufficient drug adherence. Adherence to pharmacotherapy after myocardial infarction decreases over time in a similar manner for all pivotal groups of drugs prescribed after MI. A number of socioeconomic and clinical factors have been identified to affect medication adherence over time.

Effect of Medication Adherence and Early Follow-Up on Unplanned Readmission Post-Myocardial Infarction: Quality Improvement in a Safety Net Hospital.

Medication nonadherence is a strong predictor of adverse events and unplanned 30-day readmissions in post-myocardial infarction (MI) patients. Nonadherence with dual antiplatelet therapy (DAPT) is of particular concern in post-MI patients, given the high rate of percutaneous coronary intervention in this population. Review of post-MI quality measures revealed that compared to national benchmarks, our safety net hospital had lower DAPT adherence rates and higher unplanned 30-day readmission rates. The aim was to improve these important quality measures by creating a transition of care pathway primarily focused on medication accessibility and affordability of DAPT and early follow-up. A multidisciplinary task force created a transition of care pathway that included bedside medication delivery, patient assistance program enrollment for medications, and follow-up within 10 days of discharge in a dedicated post-MI clinic. Resources for the pathway (personnel and hospital) were already available and repurposed. We compared quality measures of DAPT adherence, proportion of patients evaluated early after hospital discharge, and unplanned 30-day readmissions before and after the initiative. Following initiation of the transition of care pathway, DAPT adherence increased from 56% pre-intervention to 92% post-intervention (P < 0.0001). The proportion of patients scheduled for early clinic follow-up after discharge increased and unplanned 30-day readmissions decreased following initiation of the pathway. A transition of care pathway for post-MI patients using readily available resources was associated with increased DAPT adherence and decreased 30-day unplanned readmissions.

Myocardial Scar by Pulse-Cancellation Echocardiography Is Independently Associated with Appropriate Defibrillator Intervention for Primary Prevention after Myocardial Infarction

Myocardial scar burden impacts prognosis in patients with coronary artery disease who have experienced a myocardial infarction (MI). This has been demonstrated by late gadolinium enhancement cardiac magnetic resonance. Clinical experience with echocardiography suggests that the reflected ultrasound signal is enhanced in infarcted myocardial segments. Scar imaging with an ultrasound multipulse scheme (eScar) has been preliminarily validated in prior studies. To assess whether scar burden, as detected by eScar, is associated with implantable cardioverter-defibrillator (ICD) shocks in post-MI patients. We retrospectively selected 50 post-MI patients with an ejection fraction <35% who received an ICD for primary prevention and subsequently had at least one appropriate shock (cases). These were compared with 50 post-MI patients, matched for clinical variables and ejection fraction, who never experienced an appropriate defibrillator shock (controls). Subjects were assessed with the eScar technique at the time of implantation or during follow-up. An eScar was present in ≥1 segment in 40 of 50 (80%) cases vs 26 of 50 (52%) controls and was associated with appropriate ICD shocks (P=.004). Receiver operating characteristic curve analysis, using a threshold of ≥3 segments by eScar, showed an area under the curve (AUC) of 0.715. On models including clinical and echocardiographic variables, eScar remained significantly associated with ICD shocks (P=.050 or P=.033 depending on the model). Adding eScar to a multivariate logistic regression model including indexed left ventricular end-systolic volume led to an increase in AUC from 0.734 to 0.782 (P=.049), while substituting indexed left ventricular end-diastolic volume for indexed left ventricular end-systolic volume resulted in a nonsignificant increase in AUC from 0.747 to 0.785 (P=.098). Presence and extent of eScar were independently associated with appropriate ICD shocks in this study of patients with prior MI and reduced ejection fraction. However, the addition of eScar assessment to the clinical multivariable model that included also indexed left ventricular end-diastolic volume did not provide significant incremental value.

Established and Emerging Pharmacological Therapies for Post-Myocardial Infarction Patients with Heart Failure: a Review of the Evidence.

After an episode of myocardial infarction (MI), patients remain at risk for recurrent ischemic events, heart failure (HF), and sudden death. Post-MI patients with left ventricular systolic dysfunction (LVSD) have an even greater risk of mortality and morbidity. Randomized clinical trials that included post-MI patients with LVSD have demonstrated that pharmacologic therapies aimed at preventing post-MI remodeling with neurohormonal antagonists can significantly improve short- and long-term outcomes, including death, reinfarction, and worsening HF. Recent trials have also demonstrated benefits in terms of cardiovascular event reduction with effective antithrombotic therapies and cholesterol-lowering agents in post-MI setting, especially in patients at very high risk such as those with LVSD. This paper reviews clinical trials that included post-MI patients with LVSD, with or without signs and symptoms of HF, assessing the efficacy of established and emerging pharmacological therapies.

4448 Mental Stress Induced Myocardial Ischemia as a Marker for Adverse Cardiovascular Events After MI

OBJECTIVES/GOALS: Young and middle-aged adults with a myocardial infarction (MI) represent an understudied group potentially with unique risk indicators such as emotional stress. We sought to investigate if mental stress-induced myocardial ischemia (MSIMI), a marker of cardiovascular vulnerability to psychological stress, is associated with poor outcomes among this population. METHODS/STUDY POPULATION: We studied 306 patients (150 women and 156 men) ≤61 years of age who were hospitalized for MI in the previous 8 months. Clinical, behavioral and psychosocial factors were assessed with standardized measures. Patients underwent myocardial perfusion imaging with mental stress (public speaking) and conventional stress (exercise or pharmacological testing). MSIMI and conventional stress-induced ischemia were defined as a new or worsening perfusion defect. Patients were followed for 3 years for adverse events, which were independently adjudicated. Cox proportional hazard models were used to estimate the association of MSIMI and CSIMI with a composite endpoint of recurrent MI or cardiovascular (CV) death with adjustment for demographic, clinical and psychosocial risk factors. RESULTS/ANTICIPATED RESULTS: The mean age of the sample was 50 years (range, 22-61). MSIMI occurred in 16% of the patients, and conventional ischemia in 35%. Over a 3-year follow-up, 28 individuals had a recurrent MI and 2 died due to cardiovascular causes. The incidence of the composite endpoint of MI or CV death was more than doubled in patients with MSIMI (20%) than those without MSIMI (8%), HR 2.6, 95%CI, 1.2-5.6. Further adjustment for demographic and clinical risk factors and depressive symptoms did not substantially change the relationship. In contrast, conventional stress ischemia was not significantly related to the outcome (HR 1.4, 95%CI, 0.6-3.0). DISCUSSION/SIGNIFICANCE OF IMPACT: Young and middle-aged individuals with MSIMI after MI have a &gt;2-fold higher likelihood of recurrent MI and CV mortality compared with those without MSIMI. In this patient group, MSIMI is a better risk indicator than ischemia with a conventional stress. These findings point to psychological stress as an important determinant of risk in this patient population. Ischemia induced by mental stress is a potent risk indicator in young post-MI patients. Stress-reduction interventions may be especially beneficial in patients who show this abnormal response.

Design and rationale of the Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction: study protocol for a randomized controlled trial

BackgroundTreatment with beta-blockers is currently recommended after myocardial infarction (MI). The evidence relies on trials conducted decades ago before implementation of revascularization and contemporary medical therapy or in trials enrolling patients with heart failure or reduced left ventricular ejection fraction (LVEF ≤ 40%). Accordingly, the impact of beta-blockers on mortality and morbidity following acute MI in patients without reduced LVEF or heart failure is unclear.Methods/designThe Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction (DANBLOCK) is a prospective, randomized, controlled, open-label, non-blinded endpoint clinical trial designed to evaluate the efficacy of beta-blocker treatment in post-MI patients in the absence of reduced LVEF or heart failure. We will randomize 3570 patients will be randomized within 14 days of index MI to beta-blocker or control for a minimum of 2 years. The primary endpoint is a composite of all-cause mortality, recurrent MI, acute decompensated heart failure, unstable angina pectoris, or stroke. The primary composite endpoint will be assessed through locally reported and adjudicated endpoints supplemented by linkage to the Danish national registers. A number of secondary endpoints will be investigated including patient reported outcomes and cardiovascular mortality. Data from similar ongoing trials in Norway and Sweden will be pooled to perform an individual patient data meta-analysis.DiscussionDANBLOCK is a randomized clinical trial investigating the effect of long-term beta-blocker therapy after myocardial infarction in patients without heart failure and reduced LVEF. Results from the trial will add important scientific evidence to inform future clinical guidelines.Trial registrationClinicaltrials.gov, NCT03778554. Registered on 19 December 2018.European Clinical Trials Database, 2018-002699-42, registered on 28 September 2018.

Cost-effectiveness of low-dose colchicine after myocardial infarction in the Colchicine Cardiovascular Outcomes Trial (COLCOT)

AimsIn the randomized, placebo-controlled Colchicine Cardiovascular Outcomes Trial (COLCOT) of 4745 patients enrolled within 30 days after myocardial infarction (MI), low-dose colchicine (0.5 mg once daily) reduced the incidence of the primary composite endpoint of cardiovascular death, resuscitated cardiac arrest, MI, stroke, or urgent hospitalization for angina leading to coronary revascularization. To assess the in-trial period and lifetime cost-effectiveness of low-dose colchicine therapy compared to placebo in post-MI patients on standard-of-care therapy.Methods and resultsA multistate Markov model was developed incorporating the primary efficacy and safety results from COLCOT, as well as healthcare costs and utilities from the Canadian healthcare system perspective. All components of the primary outcome, non-cardiovascular deaths, and pneumonia were included as health states in the model as both primary and recurrent events. In the main analysis, a deterministic approach was used to estimate the incremental cost-effectiveness ratio (ICER) for the trial period (24 months) and lifetime (20 years). Over the in-trial period, the addition of colchicine to post-MI standard-of-care treatment decreased the mean overall per-patient costs by 47%, from $502 to $265 Canadian dollar (CAD), and increased the quality-adjusted life years (QALYs) from 1.30 to 1.34. The lifetime per-patient costs were further reduced (69%) and QALYs increased with colchicine therapy (from 8.82 to 11.68). As a result, both in-trial and lifetime ICERs indicated colchicine therapy was a dominant strategy.ConclusionCost-effectiveness analyses indicate that the addition of colchicine to standard-of-care therapy after MI is economically dominant and therefore generates cost savings.